Mail-Based Self-Sampling to Complete Colorectal Cancer Screening: Accelerating Colorectal Cancer Screening and Follow-up Through Implementation Science

Introduction Leveraging cancer screening tests, such as the fecal immunochemical test (FIT), that allow for self-sampling and postal mail for screening invitations, test delivery, and return can increase participation in colorectal cancer (CRC) screening. The range of approaches that use self-sampling and mail for promoting CRC screening, including use of recommended best practices, has not been widely investigated. Methods We characterized self-sampling and mail strategies used for implementing CRC screening across a consortium of 8 National Cancer Institute Cancer Moonshot Initiative Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science (ACCSIS) research projects. These projects serve diverse rural, urban, and tribal populations in the US. Results All 8 ACCSIS projects leveraged self-sampling and mail to promote screening. Strategies included organized mailed FIT outreach with mailed invitations, including FIT kits, reminders, and mailed return (n = 7); organized FIT-DNA outreach with mailed kit return (n = 1); organized on-demand FIT outreach with mailed offers to request a kit for mailed return (n = 1); and opportunistic FIT-DNA with in-clinic offers to be mailed a test for mailed return (n = 2). We found differences in patient identification strategies, outreach delivery approaches, and test return options. We also observed consistent use of Centers for Disease Control and Prevention Summit consensus best practice recommendations by the 7 projects that used mailed FIT outreach. Conclusion In research projects reaching diverse populations in the US, we observed multiple strategies that leverage self-sampling and mail to promote CRC screening. Mail and self-sampling, including mailed FIT outreach, could be more broadly leveraged to optimize cancer screening.


Introduction
Leveraging cancer screening tests, such as the fecal immunochemical test (FIT), that allow for self-sampling and postal mail for screening invitations, test delivery, and return can increase parti-cipation in colorectal cancer (CRC) screening.The range of approaches that use self-sampling and mail for promoting CRC screening, including use of recommended best practices, has not been widely investigated.

Methods
We characterized self-sampling and mail strategies used for implementing CRC screening across a consortium of 8 National Cancer Institute Cancer Moonshot Initiative Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science (ACCSIS) research projects.These projects serve diverse rural, urban, and tribal populations in the US.

Results
All 8 ACCSIS projects leveraged self-sampling and mail to promote screening.Strategies included organized mailed FIT outreach with mailed invitations, including FIT kits, reminders, and mailed return (n = 7); organized FIT-DNA outreach with mailed kit return (n = 1); organized on-demand FIT outreach with mailed offers to request a kit for mailed return (n = 1); and opportunistic FIT-DNA with in-clinic offers to be mailed a test for mailed return (n = 2).We found differences in patient identification strategies, outreach delivery approaches, and test return options.We also observed consistent use of Centers for Disease Control and Prevention Summit consensus best practice recommendations by the 7 projects that used mailed FIT outreach.

Conclusion
In research projects reaching diverse populations in the US, we observed multiple strategies that leverage self-sampling and mail to promote CRC screening.Mail and self-sampling, including

Introduction
National guidelines, such as those from the US Preventive Services Task Force (USPSTF), recommend self-sampling methods for colorectal cancer (CRC) screening through guaiac fecal occult blood testing, and more recently, fecal immunochemical testing (FIT) and FIT-DNA testing (1,2).Self-sampling methods reduce structural barriers to cancer screening by removing the burden of visiting a health care site, and self-sampling, facilitated by mailed outreach, has been shown to increase CRC screening by an absolute 28% compared with usual, visit-based screening (3)(4)(5).Selfsampling methods are increasingly proposed for addressing inequities in screening and have been envisioned by the President's Cancer Panel (6).In one integrated health system, mailed FIT outreach was a key component of a population health initiative that dramatically reduced CRC incidence (7) and eliminated disparities in CRC incidence and death between non-Hispanic Black and non-Hispanic White adults (8).
Despite its promise, mailed outreach using self-sampling is challenging to implement (9).Mailed outreach requires systems for mailing and processing samples, prompting patients to complete testing, communicating results to clinicians and patients, and ensuring timely follow-up of abnormal test results.Differences in how these systems are designed can influence how well a program is implemented and maintained and, ultimately, its effectiveness (10)(11)(12)(13).However, many health system leaders and program planners lack knowledge about how to establish and adapt these systems for their context.In response to this knowledge gap, the Centers for Disease Control and Prevention (CDC) and the National Association of Chronic Disease Directors convened subject matter experts as part of a 2018 summit to identify optimal strategies for implementing mailed FIT outreach programs.Summit attendees identified several outreach components and practices that could lead to higher completion rates (hereinafter, Summit consensus recommendations) (9) and produced a mailed FIT implementation guide (14).The extent to which Summit consensus recommendations have been adapted and implemented has not been comprehensively characterized.
The National Cancer Institute's (NCI's) Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science (ACCSIS) Consortium supports research to understand how evidence-based multilevel interventions, such as mailed FIT outreach, can be implemented and scaled to reduce the burden of CRC (15,16).Here, we present the range of approaches to promote mail-based self-sampling methods for CRC screening com-pletion implemented by 8 ACCSIS research projects and the extent to which these approaches were consistent with Summit consensus recommendations for mailed FIT outreach.This study may help illuminate strategies for promoting and supporting successful implementation of mail-based strategies for increasing CRC screening and attenuating disparities across diverse contexts.

Methods
This study was conducted as part of the NCI-funded ACCSIS Consortium.Its overall aim is to support transdisciplinary research at multiple sites to evaluate and improve CRC screening processes using implementation science.The Consortium is intended to provide an evidence base for multilevel interventions that increase rates of CRC screening, follow-up, and referral to care, and best practices for how multilevel interventions can be scaled up to reduce the burden of CRC in the US, particularly in groups with traditionally low rates of screening participation.The ACC-SIS Consortium consists of 8 five-year research projects and a coordinating center.Research projects funded through the ACCSIS Cancer Moonshot Initiative include sites in California (San Diego), Illinois and Indiana (referred to as Chicago), Kentucky and Ohio (referred to as Appalachia), North Carolina, and Oregon.Three sites are supported through cancer center supplements and focus on American Indian populations in Arizona, New Mexico, and Oklahoma.Within each research project, interventions occur at multiple clinical care subsites that include settings such as tribal clinics and federally qualified health centers (FQHCs).Individual projects were funded based on site-specific proposals, and the Consortium is supported by a central coordinating center (RTI International).Individual sites are responsible for evaluating their own project performance and reporting performance via progress reports and peer-reviewed articles.Data sharing of common data elements pertinent to screening and follow-up is required, and plans to make these data available for the broad research community are required by NCI and are in process (17).ACCSIS evaluation plans include analysis of common data elements related to screening initiation and follow-up collected across all research projects.Additionally, the coordinating center works with sites to develop opportunities for trans-ACCSIS initiatives and analyses, such as the analysis provided here.

The ACCSIS framework
The ACCSIS framework is a model for how to implement multilevel, evidence-based interventions to increase CRC screening, follow-up, and referral to care (Appendix).The framework identifies multilevel contextual factors that drive selection of evidencebased interventions, adaptations that can be made in response to local context, and an iterative process for implementing and evalu-ating the chosen interventions.The framework guides assessment of implementation success, as well as short-term and long-term outcomes (eg, increases in CRC screening and follow-up, reductions in CRC incidence and mortality).This framework provides overarching guidance for selecting the categories and data elements directly relevant to understanding how each ACCSIS research project proposes to leverage mail to promote CRC screening.

Definitions of strategies for leveraging mail to promote completion of CRC screening
To facilitate consistent descriptions of each research project, we defined ways that mail could be used to promote screening completion.We intended our definitions to distinguish differences in 1) how someone is identified as needing a screening test, 2) how the test is delivered to the patient and returned for processing, and 3) which type of self-sampling test is offered.Our definitions intended to accommodate future innovations in test distribution and test type (eg, novel fecal test approaches, blood test using selfcollection devices).For FIT, categories included organized mailed FIT outreach, organized on-demand mailed FIT, and opportunistic FIT with mailed return (Table 1).We created analogous definitions for FIT-DNA screening: organized FIT-DNA outreach, organized on-demand FIT-DNA, and opportunistic FIT-DNA.In so doing, we recognize that the only currently marketed FIT-DNA test (Cologuard) is not available for opportunistic, clinic-visitbased distribution of test kits with mailed return and that this test is not consistently available to all populations because of differences in insurance coverage and cost.

Data collection
We created structured data collection instruments to summarize site and project characteristics based on the ACCSIS conceptual framework and Summit consensus-recommended approaches for mailed FIT outreach (9).The instrument followed the ACCSIS framework goal of characterizing contextual factors, intervention characteristics, and outcome metrics.Questions for the components of mailed FIT outreach followed the Summit consensus-recommended strategies (9,14).
For this article, "project lead" or "project champion" can refer to an individual, a group, or an institution.We iteratively reviewed and refined data through discussion and email communications from January 2021 to October 2022.Summarized data reflect initial implementation strategies used.

Research ethics and regulations
Projects were approved by local institutional review boards.This article was reviewed and approved by each research project site; for American Indian sites, approval was based on local protocols for tribal leadership and Indian Health Service review.

Results
All 8 ACCSIS research projects, representing rural, urban, and tribal settings in the South, Midwest, Southwest, and Northwest, participated in this study (Figure , Table 2, Table 3).Populations served by the research projects are racially and ethnically diverse, including American Indian, Black, Hispanic, Asian American, and non-Hispanic White populations, and individuals with lower socioeconomic position, who are more likely to be medically underserved.Seven projects (Appalachia, Arizona, Chicago, New Mexico, North Carolina, Oregon, and San Diego) initially focused on offering screening to individuals aged 50 to 75 years, whereas 1 project (Oklahoma) initially offered screening to individuals aged 45 to 75 years, consistent with the most recent USPSTF guidelines.

Approach to leveraging mail for outreach
All 8 ACCSIS research projects reported leveraging mail to facilitate completion of stool-based CRC screening, with multiple approaches represented (Figure).Seven of 8 projects used organized mailed FIT outreach (Appalachia, Chicago, New Mexico, North Carolina, Oklahoma, Oregon, and San Diego).Additionally, 1 project used on-demand mailed FIT (Arizona), 2 projects used opportunistic FIT-DNA (Appalachia and Chicago), and 1 project used organized FIT-DNA (Appalachia).Four research projects reported a plan to enhance opportunistic FIT (Appalachia, Arizona, Chicago, and New Mexico), and many other projects reported that opportunistic FIT was operational in usual care.Project leads.Project leads included a nonprofit organization that supports FQHC health systems for 1 project (San Diego), 3 Medicaid health plans and affiliated clinics for 1 project (Oregon), 1 or more FQHC health systems for 3 projects (Appalachia, Arizona, and Chicago), a coalition of an FQHC health system and an academic cancer center for 1 project (North Carolina), and tribal health clinics for 3 projects (Arizona, New Mexico, and Oklahoma (Table 2).

PREVENTING CHRONIC DISEASE
Patient identification strategies.Diverse approaches were used for patient identification, including electronic health record queries (n = 7; Appalachia, Arizona, Chicago, New Mexico, North Carolina, Oklahoma, and San Diego), insurance claims data (n = 1; Oregon), electronic population health tools (n = 3; Chicago, Oklahoma, and San Diego), and upcoming patient appointment lists (n = 1; Arizona) (Table 2 and Table 3).Some research projects described additional "scrubbing" procedures in which initial data queries were reviewed to verify accuracy (n = 4; New Mexico, North Carolina, Oregon, and San Diego).The number of patients receiving mailed FIT outreach differed by research project and ranged from 180 to thousands of patients per year.
Mailed components.At a minimum, mailed components included an opportunity for self-collection and mailed return of a FIT or FIT-DNA kit (Table 2 and Table 3).For sites using opportunistic FIT-DNA (Appalachia and Chicago) and organized FIT-DNA (Appalachia), the mailed components were supplied by the manufacturer and included an invitation to complete screening, a FIT-DNA kit, and instructions on how to complete the kit and arrange for return to the FIT-DNA laboratory.
Outreach delivery and test return approaches.Outreach was delivered by a health system or clinic (Appalachia, Arizona, and Chicago), an academic cancer center (North Carolina), a thirdparty mail fulfilment service (Oregon and San Diego), and a tribal health clinic (Arizona, New Mexico, and Oklahoma).Stool test return strategies varied across research projects, and many offered more than 1 option: mailed return to a health clinic laboratory or commercial laboratory (n = 6; Appalachia, Chicago, North Carolina, Oklahoma, Oregon, and San Diego), home pickup by a case worker or patient navigator (n = 3; Appalachia, Arizona, and New Mexico), and in-person return to a health clinic laboratory (n = 5; Appalachia, Arizona, New Mexico, Oklahoma, and Oregon).
Follow-up on abnormal test results.Seven projects (Appalachia, Arizona, Chicago, New Mexico, Oklahoma, Oregon, and San Diego) offered clinic-based navigation and care coordination, and 1 project used a combination of clinic-based care coordination (usual care) plus central telephone navigation (North Carolina).Primary project outcome.For all research projects, the primary outcome was screening completion by any USPSTF guideline-recommended modality, including stool testing or colonoscopy.The time frame for assessing primary outcome ranged from completion within 6 months to within 12 months for most projects; 1 project assessed change in proportion up-to-date with screening at the health system from baseline through 3 years follow-up.

Use of Summit consensus recommendations for mailed FIT outreach across ACCSIS sites
Seven of 8 projects (all but Arizona) reported using organized mailed FIT outreach to promote screening (Table 4A and Table 4B).However, the scale of outreach varied on the basis of factors such as clinic preferences, clinic staffing, and availability of patients with home mailboxes.For example, some projects initiated batch mailings to hundreds of patients in each mailing cycle, leveraging electronic health records (North Carolina, Oklahoma, and San Diego) or claims data (Oregon), and 1 project reported that clinics mail 10 to 30 kits per month depending on staff availability (Appalachia).Project sites used all or nearly all 8 Summit consensus-recommended strategies.
Use primers such as texts, telephone calls, and printed mailings before mailed outreach.All 7 projects reported use of primers before sending a FIT by mail; however, mode of primers varied, with 6 projects reporting use of printed material (Appalachia, New Mexico, North Carolina, Oklahoma, Oregon, and San Diego), 1 project delivering a text primer (San Diego), and 3 projects reporting use of live telephone call primers in all (Chicago and Oklahoma) or some (Oregon) clinics.
Use a brief, easy-to-read invitation letter with signatory tailored to setting.All 7 projects reported efforts to use a brief, easy-to-read letter.Signatories were tailored to setting and varied from clinic directors (n = 2; New Mexico and North Carolina), to a health system or health plan (n = 3; Chicago, Oregon, and San Diego), to a health care provider or health care team (n = 2; Appalachia and Oregon), to a patient navigator (n = 1; Oklahoma).
Use simple FIT completion instructions that address challenges such as failed laboratory processing, literacy, and language.The range of FIT completion instruction types included pictorial (n = 1; Oregon), mixed pictorial and text (n = 5; Appalachia, Chicago, New Mexico, North Carolina, and San Diego), links to instructional videos (n = 1; Chicago), and manufacturer instructions (n = 3; New Mexico, Oklahoma, and Oregon).Notably, projects reporting use of pictorial, mixed pictorial and text, and instructional videos all noted efforts to optimize instructions for literacy level, and 5 projects offered instructions in a language other than English (Arizona, Chicago, North Carolina, Oregon, and San Diego).Use a high-quality, 1-sample FIT.All 7 projects reported use of a 1-sample FIT kit for at least 1 clinic site.Six (Appalachia, New Mexico, North Carolina, Oklahoma, Oregon, and San Diego) used OC-Auto and OC-Light S (Polymedco), 5 projects (Chicago, New Mexico, Oklahoma, Oregon, San Diego) used InSure ONE (Clinical Genomics), and 3 projects (Appalachia, Oklahoma, Oregon) used Hemosure iFOB Test Kit (Hemosure, Inc).Additionally, in 1 project (Oregon), a site elected to use the 2-sample OneStep+ (Henry Schein, Inc).

PREVENTING CHRONIC DISEASE
Use reminders to initial noncompleters to increase return rate.Seven projects reported use of reminders to promote screening completion, including text messages (n = 3; Chicago, Oregon, and San Diego), live telephone calls (n = 4; Appalachia, Chicago, Oklahoma, and Oregon), automated telephone calls (n = 3; San Diego, Oklahoma, and Oregon), and mailed letters (n = 2; North Carolina and Oregon).One site (New Mexico) had planned to use telephone call reminders but was unable to because of staffing shortages precipitated by the COVID-19 pandemic.
Establish a data infrastructure to identify eligible patients and track each step in the outreach process.All projects reported establishing a data infrastructure to identify eligible patients and track each outreach step.These ranged from using an electronic health record tool (n = 4; Chicago, New Mexico, Oklahoma, and San Diego), to electronic spreadsheets (n = 3; Appalachia, New Mexico, and Oklahoma), to a web-based tool from a third-party vendor (n = 3; San Diego, North Carolina, and Oregon).
Use protocols and procedures such as navigation to promote colonoscopy completion after abnormal FIT results.All projects applied protocols and procedures to promote colonoscopy after an abnormal FIT result.
Identify a project champion and organizational support to promote sustainability.The project champions varied across projects and included primary point of contact for project activities (n = 1; Oregon), clinic-based quality improvement teams (n = 5; Appalachia, Chicago, New Mexico, Oklahoma, and Oregon), a centralized quality improvement team working across multiple health systems (n = 1; San Diego), and an NCI-designated cancer center (n = 1; North Carolina).Five projects confirmed discussions about organizational support to promote sustainability of the project (Appalachia, New Mexico, North Carolina, Oregon, and San Diego).
During the process of data collection, synthesis, and discussion, several challenges to mailed FIT outreach were reported, including limited staff time to prepare and send invitations at some clinics (a challenge that was exacerbated by COVID-19); data aggregation, such as for identifying individuals for mailed FIT outreach; and navigating how to use multiple different FIT kit brands on the basis of insurance plan or clinic selection.

Discussion
Self-sampling methods combined with convenience of mail for test distribution and/or return have great potential for optimizing participation in cancer screening, including CRC screening.Among 8 ACCSIS research projects, various mail-based approaches were used, with some projects distributing tests by mail, offering mailed return of completed tests, or both.For research projects that delivered organized mail-based FIT distribution and return, nearly all Summit consensus-recommended best practices for mailed FIT outreach were implemented, suggesting that implementation is feasible across a range of geographic regions and populations.Nevertheless, we observed variation in how research projects designed and adapted outreach to address the unique needs of settings and populations.Our results have implications for using mail and self-sampling to promote the completion of screening for various cancers and offer a guide to how selfsampling tests, such as FIT, can be successfully implemented in diverse settings and populations.Specific to organized mailed FIT outreach, our observations add to the growing body of evidence supporting its viability as a strategy for promoting CRC screening across diverse settings and populations.Seven of 8 research projects reported using organized mailed FIT outreach, with consistent use of Summit consensus-recommended best practices, albeit with differences in scale and scope, form of components, and site-specific challenges.For example, 7 projects delivered reminders to increase return rates, and these reminders were in various forms: letters, live telephone calls, automated calls, and text messages.All 7 of these research projects reported using a 1-sample FIT, and 1 project (Oregon) also used a 2-sample FIT at 1 clinic.Applying findings from an evidence synthesis on FIT performance commissioned by the Agency for Healthcare Research and Quality, which concluded that adequate evidence supports the performance of OC-Auto and OC-Light (18) but not of Hemosure or InsureONE (18), we conclude that 7 ACCSIS research projects offered a high-quality 1sample FIT in at least 1 clinic or population.All projects reported using a data infrastructure to track steps in the outreach process, which facilitated monitoring of FIT return and completion of follow-up colonoscopy and could be leveraged for detecting and managing implementation issues.
Context shaped mailed FIT outreach delivery.For example, in Oregon, the ability to engage with rural Medicaid-managed care providers and challenges in producing data to support CRC outreach at rural clinics led to a mailed FIT outreach project driven by PREVENTING CHRONIC DISEASE insurance claims data and facilitated by Medicaid health plans (19).In San Diego, the presence of a nonprofit organization whose mission is to optimize health care quality across multiple FQHC systems allowed for a mailed FIT outreach project led by this centralized entity.Potential for disparities in access to an optimal mailed FIT outreach was reflected in 3 observations: 1) some lower-resource clinics had limited capacity to scale mailed outreach beyond a handful of patients per month, 2) a lack of personal US mailboxes limited access to this mailed approach for some tribal communities, and 3) the brand of FIT was driven by insurance and other factors rather than by test quality alone (20).As such, even though mailed FIT outreach has been shown to be effective for increasing screening, its reach still may be limited without large-scale structural changes (eg, funding for national, statewide, or regional mailed outreach programs; addressing postal access for tribal communities).Despite these challenges, our observations suggest that multiple approaches can be taken to successfully implement best practices for mailed FIT outreach and that flexible approaches may be needed to meet the needs of diverse populations and settings.
Our findings also illustrate areas where additional research may be warranted.Although abundant evidence supports use of mailed FIT outreach and opportunistic mailed FIT, less research supports the use of organized on-demand mailed FIT.Across types of mailbased strategies, few head-to-head comparisons have been made of opportunistic, organized on-demand, and organized outreach for promoting FIT completion.In a direct comparison of organized mailed FIT outreach and organized on-demand FIT among Medicaid beneficiaries, Brenner et al found that rates of screening completion were higher with organized mailed FIT outreach (21).No studies have reported on the success of organized outreach offering FIT compared with organized outreach offering FIT-DNA or on-demand compared with opportunistic FIT.Understanding relative effectiveness of these approaches can optimize selfsample-based cancer screening for CRC and other at-home screening or diagnostic tests, such as human papillomavirus-DNA tests, or at-home blood collection for various tests (where small quantities of blood are required).Our Summit consensus-based definitions for mail-based self-sampling strategies may facilitate more consistent reporting on evaluations of mail-based screening strategies and better ability to systematically compare these approaches.

Limitations
A few limitations may be considered in interpreting this report.ACCSIS research projects are not representative of all regions and populations in the US, although all projects attempted to conduct their studies as pragmatic studies.Implementation time frames in-cluded the start of the COVID-19 pandemic.As such, observations reported here might have been different if the pandemic had not occurred, but they do reflect the likely reality of a context in which COVID-19 remains active and at least endemic.

Conclusion
Across a range of research projects representing diverse regions and populations in the US, we observed multiple strategies for leveraging self-sampling and mail for CRC screening, from organized FIT outreach to opportunistic offers for FIT or FIT-DNA with mailed return.Furthermore, 7 of 8 projects successfully implemented mailed FIT outreach, including the use of nearly every best practice strategy for mailed FIT implementation.Our observations suggest that great potential remains for more broadly leveraging mail and self-sampling for cancer screening, including with mailed FIT outreach.Additionally, this work serves as a foundation for future ACCSIS research that can compare how outcomes of screening promotion (ie, screening and follow-up colonoscopy participation) differ by implementation strategies used.Understanding relative performance of different implementation strategies could help optimize self-sampling-based cancer screening for CRC and other screening and diagnostic tests.
Coronado GD, Leo MC, Ramsey K, Coury  Organizational-level (eg, health system, health clinic, health insurance plan) or population-level identification of patients not up-todate with screening for mailed outreach including a FIT kit with a postage-paid envelope to return the FIT to the laboratory via mail.
May have a centralized component that crosses clinics within a system, individuals within a population, or health systems within a region.A common modification for clinic-and health system-based outreach is to specify or allow a patient to return a FIT to a laboratory or clinic by hand instead of through mail.Mailed FIT outreach is distinct from approaches that use FIT-DNA as the testing strategy.
Organized on-demand mailed FIT Organizational-level or population-level outreach, via mailed letter, text message, or telephone call, to patients not up-to-date with screening to opt in to receive a FIT kit with a postage-paid return envelope.A common modification is for a patient to return a FIT to a laboratory or clinic by hand instead of through mail.
Opportunistic a Appalachia tested 5 additional strategies (Table 3).b Chicago tested 1 additional strategy (Table 3).Mailed FIT team at health system.Each participating CCO and clinic site identified a primary point of contact and implementation team.These leads helped support the decision to take part in the research study and subsequent implementation and evaluation

PREVENTING CHRONIC DISEASE
The project champion is a central quality promotion organization.
The organization has initiated conversations with other partners to develop policy and funding strategies for sustaining mailed outreach beyond the grant Abbreviations: CCO, coordinated care organizations; CRC, colorectal cancer; EHR, electronic health record; FIT, fecal immunochemical test; FQHC, federally qualified health center; SMS, short messaging service.a The Centers for Disease Control and Prevention and the National Association of Chronic Disease Directors convened subject matter experts as part of a 2018 summit to identify optimal strategies for implementing mailed FIT outreach programs.Summit attendees identified 8 outreach components and practices that could lead to higher completion rates (9).b Arizona did not use mailed FIT outreach, but as part of on-demand mailed FIT, the project used many components often included as part of mailed FIT outreach;

Figure
Figure.ACCSIS consortium members, research project sites, and mail-based strategies used for promoting CRC screening.Abbreviations: ACCSIS, Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science; CRC, colorectal cancer; FIT, fecal immunochemical test.
opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.
opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.
VOLUME 20, E112 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY DECEMBER 2023 The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.
opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.
these are shown for comparison.(continued on next page) PREVENTING CHRONIC DISEASE VOLUME 20, E112 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY DECEMBER 2023 The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.

Table 1 .
J, Petrik AF, Patzel M, et al.Mailed fecal testing and patient navigation versus usual care to improve rates of colorectal cancer screening and follow-up colonoscopy in rural Medicaid enrollees: a cluster-Perdue LA, Henrikson NB, Bean SI, Blasi PR.Screening for Colorectal Cancer: An Evidence Update for the U.S. Preventive Services Task Force.Evidence Synthesis No. 202.Agency for Healthcare Research and Quality; 2021.The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.Strategies for Leveraging Mail to Promote Colorectal Cancer Screening With Stool-Based Tests

Table 2 .
FIT with mailed returnOpportunistic in-person or virtual clinic-based or other health visit-based distribution of FIT to patients not up-to-date with screening with a postage-paid envelope to return FIT to laboratory.Opportunistic invitation could be based on in-visit invitation or review of scheduled patients not up-to-date with screening before a visit to prepare orders.orpopulation-levelidentification of patients not up-to-date with screening for mailed outreach including a FIT-DNA kit with instructions for completion and sample pickup by a mail courier.Organized on-demand FIT-DNA Organizational-level or population-level outreach via mailed letter, text message, or telephone call, to patients not up-to-date with screening to opt in to receive a FIT-DNA kit with instructions for completion and sample pickup.Opportunistic FIT-DNA Opportunistic in-person or virtual clinic-based or other health visit-based offer of a FIT-DNA kit to patients not up-to-date with screening with FIT-DNA order for laboratory to mail patient FIT-DNA kit with instructions for completion and sample pickup.Characteristics of 8 ACCSIS Sites and Primary Strategies for Leveraging Mail for CRC Screening Completion Abbreviation: FIT, fecal immunochemical test.aExactSciences'follow-upfororderedCologuardincludesoutreach to explain testing process to patient, mailing kit to patient, and answering questions about test completion.Exact Sciences' follow-up does not include reporting results to patient or coordination of colonoscopy for abnormal test results.The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.American Indians aged 45-75 years at average risk for CRC served by tribally operated health care facilities North Carolina Ages 50-74, not up-to-date, served by 1 of 2 FQHC systems Oklahoma American Indians aged 45-75 years at average risk for CRC served by 1 tribally operated health care group (8 clinics), 1 Indian Health Service-affiliated tribal clinic, and 1 urban clinic Oregon Ages 50-74, Medicaid and dual (Medicaid-Medicare) recipients in 28 clinics served by 3 Medicaid health plans bOrganized mailed FIT outreach (12 clinics within 1 FQHC health system in Indiana); see Table3for additional strategies used a Appalachia tested 5 additional strategies (Table3).bChicagotested 1 additional strategy (Table3).The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.

Table 2 .
Characteristics of 8 ACCSIS Sites and Primary Strategies for Leveraging Mail for CRC Screening Completion AppalachiaLetter, CDC's "Screen for Life" CRC screening fact sheet, low-literacy instructions Arizona Cover letter, CRC education, FIT instructions, FIT return mailer packet, postage included Chicago Letter and FIT kits, patient reminders using text messages with hyperlinks to educational written materials and videos, reminder telephone call by patient navigator if FIT not completed within 60 days a Appalachia tested 5 additional strategies (Table3).bChicagotested 1 additional strategy (Table3).The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.

Table 2 .
Characteristics of 8 ACCSIS Sites and Primary Strategies for Leveraging Mail for CRC Screening Completion test results delivered by the clinic-based navigator via telephone.For abnormal test results, each clinic's study navigator tracks and leads patients through the process of completing a diagnostic colonoscopy.
ChicagoFollow-ups for abnormal test results by a patient navigator at the FQHC system New Mexico For normal test results, clinic sends a letter with results.For abnormal test results, a public health nurse based at the clinic provides navigation for diagnostic colonoscopy.North CarolinaFor normal test results, a letter is sent.Abnormal test results are communicated to patients through usual care processes, and followed with care coordination per usual care, as well as centralized telephone-based navigation by the outreach team Oklahoma Telephone call or letter with an informative pamphlet sent to the patient by clinic-based patient navigator Oregon For normal test results, patients received either a letter or telephone call from the clinic or the vendor (workflow tailored to setting).For abnormal test results, patients receive a telephone call from the provider/care team or from a central care management team (1 CCO).Patient navigators from the clinics follow up with all abnormal FIT results to support colonoscopy completion.San Diego Individuals with abnormal FIT results are tracked and navigated at the clinic level by using a project-specific protocol.Individuals with normal FIT results receive letter as well as usual care clinic processes.

Table 3 .
Characteristics of and Additional Strategies Used by Appalachia and Chicago ACCSIS Sites for Leveraging Mail for CRC Screening Completion Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science; CDC, Centers for Disease Control and Prevention; CRC, colorectal cancer; EHR, electronic health record; FIT, fecal immunochemical test; FQHC, federally qualified health center.
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.

Table 4A .
Use of 8 Summit Consensus Recommendations for Mailed FIT Outreach Across 7 ACCSIS Projects That Used Mailed FIT Outreach The Centers for Disease Control and Prevention and the National Association of Chronic Disease Directors convened subject matter experts as part of a 2018 summit to identify optimal strategies for implementing mailed FIT outreach programs.Summit attendees identified 8 outreach components and practices that could lead to higher completion rates (9).bArizona did not use mailed FIT outreach, but as part of on-demand mailed FIT, the project used many components often included as part of mailed FIT outreach;The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. a

Table 4A .
Use of 8 Summit Consensus Recommendations for Mailed FIT Outreach Across 7 ACCSIS Projects That Used Mailed FIT Outreach The Centers for Disease Control and Prevention and the National Association of Chronic Disease Directors convened subject matter experts as part of a 2018 summit to identify optimal strategies for implementing mailed FIT outreach programs.Summit attendees identified 8 outreach components and practices that could lead to higher completion rates (9).b Arizona did not use mailed FIT outreach, but as part of on-demand mailed FIT, the project used many components often included as part of mailed FIT outreach; these are shown for comparison.
Abbreviations: ACCSIS, Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science; CDC, Centers for Disease Control and Prevention; CRC, colorectal cancer; EHR, electronic health record; FIT, fecal immunochemical test; FQHC, federally qualified health center.aTheopinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.

Table 4B .
Use of 8 Summit Consensus Recommendations for Mailed FIT Outreach Across 7 ACCSIS Projects That Used Mailed FIT Outreach The Centers for Disease Control and Prevention and the National Association of Chronic Disease Directors convened subject matter experts as part of a 2018 summit to identify optimal strategies for implementing mailed FIT outreach programs.Summit attendees identified 8 outreach components and practices that could lead to higher completion rates (9).bArizona did not use mailed FIT outreach, but as part of on-demand mailed FIT, the project used many components often included as part of mailed FIT outreach;The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. a

Table 4B .
Use of 8 Summit Consensus Recommendations for Mailed FIT Outreach Across 7 ACCSIS Projects That Used Mailed FIT Outreach